State health officials don't think Arkansas hospitals will see severe shortages of staffers, ventilators or medical supplies during the covid-19 pandemic.
That means development of a plan on how to dole out those resources, should they become scarce, has been pushed to the side for now.
Dr. Jerrilyn Jones, preparedness medical director for the Arkansas Department of Health, said she'd been tasked with building the plan when she was hired in January 2019.
Creating such a plan, known as "crisis standards of care," often takes states many years and has been picked up a couple of times during health crises in Arkansas, she said.
"There have been rumblings," Jones said.
Some of these "rumblings" were sparked by the 2009 spread of the H1N1 flu, the 2012 issuance of a report on crisis standards of care from the Institute of Medicine and the 2013 release of standards from the same group, Jones said.
The institute is a Washington, D.C.-based nonprofit that offers advice to decision makers and the public, according to information on its website.
The University of Arkansas for Medical Sciences has its own crisis standards of care guidelines in place, adjusted for covid-19, although the system hasn't had to use most of its policies.
At the beginning of the outbreak in Arkansas, certain UAMS staff members such as pregnant women and those with preexisting conditions or over age 60 were offered the option not to work in a clinical setting to avoid exposure, UAMS Medical Center chief executive Dr. Steppe Mette said.
Very few took the option.
Although UAMS hasn't seen supply shortages like those in China, Italy, New York or Washington, the system is planning to obtain more ventilators for the future.
"We don't anticipate this [shortage] right now, but honestly we're not letting our guard down, and we are continuing to plan for the second or even third wave," Mette said.
While Arkansas' crisis standards of care policy likely won't be done soon, and there isn't a set timeline for completion, Jones said she thinks the pandemic may have sped up the sometimes yearslong process.
"We get hit with covid-19, and I think that brought things into the forefront, and I think more people are going to get asked to discuss it," Jones said.
At least 30 states have crisis standards of care policies, according to an analysis by the Center for Public Integrity, a nonprofit news organization based in Washington, D.C.
Some states worked quickly to develop and update their standards as covid-19 overwhelmed hospital supplies and health care workers in some of the country's hardest-hit states.
Others, such as Washington state, developed one years ago, Jones said.
UAMS' original guidelines were developed years ago and are periodically adjusted when the system anticipates a possible crisis such as the SARS outbreak in 2003 and the 2014 Ebola outbreak, Steppe said.
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The only one the hospital has had to implement is increased consideration of CPR efforts, particularly for patients who have said they don't want to be resuscitated. This is to limit virus exposure for health care workers -- at least 900 UAMS workers have had to be quarantined, although the first instance of exposure from a patient to a staff member didn't occur until earlier this month, Steppe said.
"It's a huge burden on health care workers, as you can probably imagine," Mette said of implementing crisis standards. "What we do every day is an effort to do whatever we can to save lives and to preserve the health of as many patients as we can. And this changes that to some degree."
Arkansas health officials met in April to discuss the state plan. During the meeting, they discussed basing Arkansas' standards on the plan from Washington state, according to meeting notes from April 9, obtained by the Arkansas Democrat-Gazette through an open records request.
Documents from Washington state include recommendations to plan for surges of patients. For example, in the event of a widespread virus like the new coronavirus, staff members with preexisting conditions could be given assignments in which they don't deal directly with infected patients.
The documents also include two sets of flow charts to determine what to do if the number of intensive care unit beds are stretched thin. The first is a set of questions to determine what to do about adult patients; the other is a set for children.
When considering whether to reallocate resources for adults, health care professionals are asked to consider the amount of time the patient will likely need critical care; the prognosis; any underlying health conditions; the degree of any organ dysfunction; and baseline functional status such as loss of energy, physical ability and cognition.
For those adults in comas, those with non-survivable head injuries, those with certain underlying health conditions or those with severe burns who have a low chance of survival, health care providers should consider transfers to out-patient care, the documents say.
Underlying health conditions "that predict poor short-term survival, despite standard treatment," are: heart failure; lung disease; central nervous system, organ or certain cancers with a poor prognosis for recovery; and severe cirrhotic liver disease with multi-organ dysfunction.
Those who are placed in intensive care should be reevaluated every 24 hours, the documents say.
Considerations for children are similar but include extreme prematurity and severe chromosomal abnormalities. The flow chart also includes consultations with the child's guardians.
These aren't necessarily the exact standards Arkansas plans to adopt, Jones said. She plans to spend time gathering groups of stakeholders to develop recommendations -- the Health Department doesn't plan to implement crisis standards as requirements, but as guidelines.
The stakeholders group would include health care professionals, advocates and "the layperson," Jones said.
Disability-rights groups in at least four states, including Washington, have filed complaints with the federal government about the policies, arguing that they were discriminatory. The U.S. Department of Health and Human Services issued a March 28 memo about civil rights and the coronavirus.
"In this time of emergency, the laudable goal of providing care quickly and efficiently must be guided by the fundamental principles of fairness, equality, and compassion that animate our civil rights laws," the memo read in part.
At UAMS, guidelines were developed with input from staff members from several disciplines, including ethics experts, clinicians, nurses and administrators, Mette said.
Ideally, in an crisis scenario, decisions about individuals' care won't be left up to just the health care provider, Jones said. She added that she'd hope systems can establish ethics committees to consider decisions of this type.
"It puts people's mortality kind of in their face," she said. "It obviously is just a very sensitive subject."
A Section on 05/18/2020